Alcohol Withdrawal with Delirium Tremens

Audience Emergency medicine (EM) residents (1st year and 2nd year levels), 4th year medical students and advanced practice providers Introduction Alcohol use has played a major role in causing significant morbidity and mortality for patients. In 2016, it was the 7th leading risk factor for deaths and disability-adjusted life years globally.1 Among heavy alcohol users admitted for hospital management, the incidence of alcohol withdrawal syndrome is estimated to be 1.9 to 6.7%.1 Alcohol withdrawal (AW) in the ED has been associated with increased use of critical care resources, and frequent ED visits for alcohol-related presentations have been associated with mortality rates that are about 1–4% when withdrawal progresses to delirium tremens (DTs).1 Patients with alcohol withdrawal can present in many different ways to the ED including anxiety, tachycardia, delirium tremens (DTs), seizures and severe autonomic dysfunction leading to severe sickness and death.2 Therefore, it is extremely important for an EM physician to recognize the signs of AW in patients and to manage the critically ill patients. In addition, Clinical Institute Withdrawal Assessment (CIWA) of alcohol was developed to assess severity of alcohol withdrawal in 1989.3 EM physicians should utilize CIWA to help determine the severity of AW. Educational Objectives By the end of the session, learner will be able to 1) discuss the causes of altered mental status, 2) utilize CIWA scoring system to quantify AW severity, 3) formulate appropriate treatment plan for AW by treating with benzodiazepine and escalating treatment appropriately, 4) treat electrolyte abnormalities by giving appropriate medications for hypokalemia and hypomagnesemia, and 5) discuss clinical progression and timing to AW. Educational Methods This session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. The session was run during first year EM resident intern orientation, and it was run during two consecutive years. There was a total of 32 EM residents who participated. There was a total of 16 residents who actively managed the patient while the other 16 were observers. Each session had four learners and was run twice in two separate rooms. There was one simulation instructor running the session and one simulation technician who acted as a nurse. Research Methods After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the participants. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right the amount of complexity (based on their Gestalt), (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. The responses were collected using a Likert scale of 1 to 5 with 1 being “Strongly disagree” and 5 being “Strongly agree.” Results There was a total of 15 respondents from both years. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning, in improving medical knowledge and in patient care. All of them found the post-session debrief to be very helpful. Two of them felt neutral about the case being realistic. The median response for questions 1, 3 and 5 is 5. The median response for questions 2 and 4 was 4. The range of responses for questions 1, 2, 3 and 5 was 4–5 while the range for question 4 was 3–5. Discussion This high-fidelity simulation was a cost-effective and realistic way of educating learners on how to manage AW with DTs. Learners are forced to start with a broad differential for the patient who presents with AMS. As they recognize the cause of mental status, the patient quickly decompensates into developing severe agitation and autonomic dysfunction requiring learners to manage the patient and establish an airway. Learners found the case to be beneficial in learning the management of AW. Topics Alcohol withdrawal, delirium tremens, agitation, altered mental status.

There were a total of 15 respondents from both years. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning, in improving medical knowledge, and in patient care. All of them found the postsession debrief to be very helpful. Two of them felt neutral about the case being realistic. The results are shown in Chart 1.

Survey questions
Median Range Q1. The case was believable. 5 4-5 Q2. The case had a right amount of complexity (based on their Gestalt). The table above shows the median and range values based on allotting number values to each of the Likert scale responses as shown in the graph. The median response for questions 1, 3 and 5 is 5, which indicates that the majority of the respondents strongly agreed that the case was believable, that it helped improve patient care and knowledge, and that the debriefing section was helpful. The median response for questions 2 and 4 was 4, which indicates that the majority of the respondents agreed that the case had the right amount of complexity and that the simulation environment gave the learners real-life experience.
The range of responses for questions 1, 2, 3 and 5 was 4-5, which indicates that learners either agreed or strongly agreed that the case was believable, that it had the right amount of complexity, that it helped improve their medical knowledge and patient care, and that the debriefing session after simulation was helpful. The range for question 4 was 3-5, which shows that while the majority of the learners agreed or strongly agreed that the simulation gave them real-life experience, a few of them felt neutral about the case being realistic. The results show that the case was helpful in improving learner's medical knowledge and that the debrief session was helpful in learning about the case. Furthermore, the majority of the learners agreed that the case gave them real-life experience and that the case had the right amount of complexity.
Comments from the survey: • "Great debriefing session! Provided a lot of good information when it comes to recognizing and treating alcohol withdrawal. Maybe cover dosing a little more for the phenobarb, other than that it was awesome!" • "Very tough but great case!" • "Overall, great case " • "Very realistic"

Case Description & Diagnosis (short synopsis):
A 49-year-old female brought in by husband for "not acting right." The history is given by the patient's husband only since the patient is very altered. The husband reports that the patient has been having nausea and vomiting for about a day and a half prior to arrival. After further questioning, the husband reports that the patient has alcohol use history which includes more than 6-pack of beer every day for over 10 years.
In the ED, patient will be alert and oriented to self only with shakiness of upper extremities, visual hallucinations, and diaphoresis. She will also be very tachycardic and hypertensive. As the case progresses, the patient will continue to complain of visual hallucinations and be very tachycardic. Despite administration of benzodiazepines, she will continue to be tremulous and diaphoretic. After phenobarbital is administered, patient will begin vomiting, prompting intubation and admission to the intensive care unit (ICU).

Equipment or Props Needed:
• High-fidelity simulation manikin which has seizure capability Initial presentation: Patient is a 49-year-old female with a past medical history of alcohol abuse and is brought in by her husband for altered mental status.
Husband reports: He states that she had been nauseous and vomiting about a day and a half ago. He notes she was very sweaty but did not have a fever. She had told him at that time she thought she had a stomach bug. However, over the past day, the husband states that she has not been acting herself and has seemed more confused. She was also complaining of a headache. He notes that they have eaten the same foods, and he has not gotten sick. He reports that the patient seemed to be picking at her skin prior to the patient's becoming more confused. Patient currently complaining of nausea, but no abdominal pain or vomiting.
In the emergency department (ED), the patient is alert and oriented x 1.
How the scene unfolds: Upon initial presentation to the ED, learners will determine that the patient is not able to provide any history, and they will need to get the full history from the husband. After history and physical examination, the patient will be found to be agitated, tremulous, and hallucinating. Learners will need to give an appropriate dosing of medication (benzodiazepines) to help the patient with her vital signs and her symptoms. Depending on the type of benzodiazepines given, the duration of action will change. They will need to continue to escalate the dosing of the benzodiazepines and look for the effectiveness of the medication. They will also need to adjust the dosing of benzodiazepine by assessing the patient's deep tendon reflexes, which will become decreased due to the sedating effects on the central nervous system. During this time, the ECG and laboratory results will be provided. Learners will need to address the electrolyte abnormalities in the laboratory results. Despite multiple administrations of the benzodiazepines, the patient will continue to be agitated. Learners will need to administer appropriate weight-based dosage of phenobarbital. After phenobarbital is administered, the patient will be altered and will require airway establishment by the learners. After airway management, the intensivist will need to be called for admission to the intensive care unit (ICU). General Appearance: slightly agitated, tremulous, diaphoretic, picking at things, protecting airway, alert and oriented to self Primary Survey: • Airway: "get these ants off of me" • Breathing: Clear to auscultation bilaterally. No rales or rhonchi • Circulation: Tachycardic with bilateral radial and dorsalis pedis pulses present

History:
• History of present illness: Patient is a 49-year-old female with a past medical history of alcohol abuse brought in by husband for "not acting right." Husband reports: He states that she had been nauseous and began vomiting about a day and a half ago. He notes she was very sweaty but did not have a fever. She had told him at that time she thought she had a stomach bug. However, over the past day, the husband states that she has not been acting herself and has seemed more confused. She was also complaining of a headache. He notes that they have eaten the same foods, and he has not gotten sick. He also remembers that the patient seemed to be picking at skin prior to the patient becoming more confused. Patient currently complaining of nausea, but no abdominal pain or vomiting.
In the emergency department (ED), the patient is alert and oriented x 1. State 2 2:00 -5:00 Discuss the differential for altered mental status and/or agitation.
Team will need to calculate CIWA.
Order laboratory studies, ECG and imaging.
CIWA assessment: Nausea/vomiting: Constant nausea and frequent dry heaving (Score = 7). Tremor: Tremor with any movement (score = 7). Sweats: beads of sweat on forehead (score = 4). Agitation: moderately fidgety and moderately restless (score = 5). Tactile disturbances: mild itching, pin and needles, burning or numbness (score = 2). Auditory disturbances: mild harshness or ability to frighten (score = 2). Visual disturbances: mild sensitivity (score = 2). Headache, fullness in head: mild headache (score = 2). Orientation: disoriented for date by no more than 2 calendar days (score = 2). Let learners come up with the CIWA which is 33; if they don't calculate CIWA, nurse will ask, "What is the CIWA?" Lorazepam takes a few minutes longer to work than midazolam when given IM. Learners will need to be specific in dosing of the medications.
If benzodiazepines are not given, patient will continue to be agitated and IV cannot be placed. If haloperidol is given, it will not work. Assess patient's airway and proceed to endotracheal intubation.
Patient is obtunded and not answering any questions or following commands.
Learners will need to be establish airway while being specific about the equipment and medication dosages.
Consider adding a nurse or husband prompt about the patient's becoming less responsive, or adding something that would indicate an inability to protect her airway as the prompt for intubation. Patient is intubated and sedated.
Intensivist will agree to admit the medical ICU. Patients presenting to the ED with alcohol withdrawal often can have their symptoms attributed to other causes. 1 In addition, other underlying medication conditions can precipitate alcohol withdrawal. Due to this confounding clinical presentation, it is incredibly important for clinicians to maintain a high suspicion for alcohol withdrawal. This is especially true because the diagnosis is a clinical diagnosis and not based on one laboratory test or imaging result. 4 Additionally, it is incredibly important to continue to evaluate for other causes of symptoms. While it is difficult to discern between these diagnoses initially, which is why it is important to evaluate for all of them, there are some clues discussed in Table 1 that can help the learner. Learners need to understand that alcohol withdrawal is a disease spectrum presenting as anxiety to delirium tremens, the most extreme presentation with a mortality rate of 2-3%, as our patient did. 4 Here are the stages of alcohol withdrawal and their time of onset: • < 6 hours -uncomplicated withdrawal is marked by anxiety, headache, nausea, vomiting, insomnia , mild tremors and mild to moderate autonomic instability. • 8-12 hours -alcohol hallucinosis is marked by auditory, visual, tactile, gustatory and olfactory hallucinations with a possibility of paranoia and delusions. • 12-24 hours -alcohol withdrawal seizures with generalized tonic-clonic seizures that occur in clusters with up to 3% progressing to status epilepticus. • 24-72 hours -alcohol withdrawal delirium which is marked with confusion and alteration in consciousness, severe autonomic changes and persistent hallucinations. 1 A tool learners can use to aid their diagnosis is the clinical institute withdrawal assessment for alcohol (CIWA). This scoring system is helpful in risk-stratifying patients initially into treatment subgroups (oral benzodiazepines vs IV benzodiazepines) and likely disposition based on presenting symptoms and exam findings. 3,4 In order to use the tool, a clinician ranks a patient on 10 separate questions/categories on a scale from 0 to 7 based on severity . 3 These 10 categories include: nausea and vomiting, tremors, paroxysmal sweats, anxiety, agitation, tactile, auditory and visual disturbances, headache and orientation. 3 Of the 10 categories, three rely on the clinician's observation of the patient (tremors, paroxysmal sweats and agitation), while the rest of the questions rely on the patient's answer. This introduces room for error due to the subjectivity of the scale based on a patient's communicative ability (language, mental status, other comorbidities such as previous stroke with speech difficulties).

Milestones assessment:
Milestone Did not achieve level 1 Level Did not achieve Level 1 Asks patient for drug allergies Selects an medication for therapeutic intervention, consider potential adverse effects Selects the most appropriate medication and understands mechanism of action, effect, and potential side effects Considers and recognizes drug-drug interactions